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- <br /> ;e� 4 . Manufactured Home Trip Permit Application <br /> 0-r $ Department of Consumer and Business Services <br /> tip <br /> >, Building Codes Division <br /> 1535 Edgewater St.NW,Salem,Oregon•Phone: 503-378-4530 • Fax: 503-378-4101 <br /> Web: oregon.gov/bcd•Email: mhods.bcd@oregon.gov <br /> This application must be submitted with a valid tax certification from the county in which the home is currently located, <br /> as well as the county the home is moving to.A valid tax certification is one that has been certified by the county.and.. <br /> submitted before the expiration date provided by the county at the time of certification. <br /> • <br /> ,..: .... . . . ;APPLICANT:;:INFORMATION <br /> Name:Factory Homes Clearance Cente Inc <br /> Address(including city,state,and ZIP):18150 SW Boones Ferry Rd Portland, OR 97224 _ .. . <br /> -Phone:971-224-2244 <br /> Email:janetm@gunnerllc.com <br /> TRANSPORTER INFORMATION . <br /> Naine:Phil Sterline <br /> Address(including city,state, and ZIP):17230 Beck Rd Dallas, OR 97338 <br /> Phbne:503-932-2629 <br /> Email:philsterlingl@gmail.com <br /> . ION ': :' .:::' :i :. .` <br /> . .. .: :: .. `.HOME:INFORMAT .... _. <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Sandpointe Year:2023 <br /> HUD label numbers:ORE 560803 <br /> ;Serial iitmlbers:FLE210OR23-23071A <br /> ;::;ADDRESS INFORMATION :';: .:: .:...: ... <br /> Current location(including city, state,ZIP):2655 Progress Way Woodburn OR 97071 County:Marion <br /> Manufactured home park name,if applicable: <br /> ; p Oregon dealer lot Dealer name: <br /> ❑Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city,state,ZIP):2200 Lancaster Dr SE #18A Salem OR 97317 County:Marion <br /> Manufactured home park name,if applicable: <br /> ❑Oregon dealer lot Dealer nail . <br /> Applicant signature: <br /> ::Amount ` `: <br /> Trip permit(per section) $5.00(70511-1195) $5.00 <br /> ;TOTAL $5.00 <br /> Make check or money order payable to Department of Consumer and Business Services.If paying by credit card,applicant <br /> must sign credit card information box.Do not send cash.Secure fax:503-947-2333 <br /> ❑Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> Credit card number Expiration <br /> i • CBS <br /> Bu4nennS <br /> Comume'Lel <br /> 440-5225(10/17/COM)_ <br />